by Elyse M. Rogers

Heartburn and Hiatus Hernia

During the week of Sept. 6, the Collegium Internationale Chirugiae Digestivae (C.I.C.D.) met at Keio Plaza. For those unfamiliar with Latin, it means the international congress for surgeons who specialize in di­gestive diseases. Over 700 papers were presented to more than 1,200 physicians who at­tended the congress from more than 43 countries. Most of the papers and seminars dealt with surgical techniques or technical studies that are of interest only to physicians, but I did talk to some of the surgeons attending the conference and they passed on some information which I think it interesting and helpful.

Dr. Hiram Polk Jr., head of surgery at the University of Louisville, is a general surgeon, but he presented a paper and talked to me about a problem that is common to many people —heartburn.

To understand the treatment for heartburn, it’s helpful to understand the basic anatomy and physiology of the eso­phagus. Very briefly, when we swallow food, it gets to the stomach through a tube that is about 10 inches long, called the esophagus. The esophagus passes through a narrow opening in the diaphragm before it empties into the stomach, and this is important because it means the esophagus is in the thoracic cavity while the stomach is totally within the abdomen.

At the juncture where the esophagus meets the stomach is a muscular ring that’s called the cardiac sphincter; this allows the passage of food into the stomach and prevents stomach contents from flowing back into the esophagus. The esophagus is a muscular tube that propels the food into the stomach by peristalsis.

That’s the normal situation. Two problems commonly occur that can cause heartburn. One is called achalasia: when the lower end of the esophagus gets narrow and restricts the passage of food. Another com­mon occurence, that Dr. Polk estimates is present in about 10% of all persons over 45, is a hiatus hernia. In this condi­tion the opening in the diaph­ragm through which the esophagus passes becomes enlarged and the upper stomach pushes up through that opening into the thoracic cavity. Hiatus hernia, or more correctly hiatal hernia, means simply that there is a protrusion (hernia) of the stomach through the opening (hiatus) of the diaphragm.

Both of these abnormal con­ditions can cause heartburn. In achalasia, the heartburn is caused by the retention of food within the esophagus; in hiatal hernia the heartburn is caused by the backflow of stomach acid into the esophagus. The patient with achalasia usually has other symptoms too—he feels as though the food “sticks in his throat” and he may have difficulty swallowing. In addi­tion, he may regurgitate the trapped food.

In hiatal hernia, the major complaint is heartburn and pain in the area of the sternum (breast bone) or around the heart. As Dr. Polk explained to me, “Patients often have difficulty describing pain or ex­plaining symptoms with some illnesses—but not in this case. When they have hiatal hernia they all describe heartburn in the same way—as a burning sensation smack in the middle of the chest.”

If a patient has symptoms of heartburn, difficulty in swallowing or has intermittent vomiting or other complaints, he should see a physician. Usually, the upper-GI series is recommended for diagnosis. This is an X-ray examination in which the patient drinks a milkshake-type mixture that contains barium sulfate, and then X-rays are taken. Barium sulfate shows up well on X-ray, and in this case will out­line the upper digestive system and show any abnormalities of the esophagus and stomach. Fortunately, it is an easy and painless test.

For the patient who is diagnosed as having achalasia, the treatment of choice is surgical repair—either by sim­ple dilitation of the stricture or by major surgery in which the narrow part of the es­ophagus is rebuilt.

For hiatal hernia, which is the more common problem, medical treatment is tried first, and is often successful. The medical treatment procedures are relatively simple, and many of the steps are ones we all would do well to follow:

  • Maintain proper weight. Dr. Polk states that the ma­jority of his hiatal hernia patients are overweight, and it is the physical action of the weight itself, in many cases, that causes heartburn or hiatal hernia.
  • Avoid tight garments. A particular offender in this area is the tight girdle. Dr. Polk says that one third of middle-aged women with hiatal hernia are cured by simply removing their girdles. He told about a women who had flown in from California for the sur­gery, and was spared surgery when he suggested she first  removing her corset. She had immediate relief and never did need the surgery.
  • Elevate the head of the bed. This mechanical measure helps keep the stomach in its proper position by gravity.
  • Limit after-dinner fluids. Since a full stomach is more likely to cause discomfort, keeping the stomach as empty as possible before reclining in bed for the night, is helpful.
  • Watch spicy foods. Even those of us who have no anatomical problems get heart­burn occasionally after a spicy pizza or a hot tamale dinner. Spicy foods irritate the lining of the stomach.
  • Go easy on coffee, tobac­co and alcohol.  These sub­stances irritate both the esophagus and the stomach, moderation is important.
  • Don’t overeat. Resist the urge to have another piece of pie when you’re more than satisfied, or to overeat at a favorite meal. A typical Thanks­giving dinner will give heart­burn and abdominal discom­fort to any overzealous diner.
  • Use antiacids—but spar­ingly. For occasional hearburn, antiacids can provide safe relief. If you’ve got to pop Turns or Gelusil every hour, that’s a severe problem that may need surgical treatment.

For those who do not respond to medical treatment or have severe esophagitis (inflamation of the esophagus) due to irritation by stomach acid that backs up into the esophagus, surgery may be recommended. The most usu­al surgical procedure is simply to pull the stomach back into the abdomen and narrow the diaphragm opening so that the stomach will remain in its proper place. The one nice thing about this surgery is that it is simple (most general surgeons can do it), safe (mortality rate is under 1%), and over 90% of patients are cured of all symptoms.

It’s rather reassuring to know that the symptoms of heart­burn and even difficulty in swallowing can be caused by benign conditions of the esophagus rather than the dreaded cancer. Only about 2% of all cancer deaths in the U.S. are clue to cancers of the esophagus, although the rate in Asia is higher. Drinking large quantities of hot tea, eating heavily smoked foods and eating highly spiced foods (in some Asian countries) seems to increase one’s susceptibility to esophageal cancers.

So, for enjoying Tokyo without heartburn, keep thin, loosen that belt… and drink your ocha lukewarm!